Careers

Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)

Yes No

The amendments to the Exceptions Order 1975 (2013) provide that certain convictions and cautions are protected and are not subject to disclosure to employers and cannot be taken into account

Yes No

Failure to declare or the falsification of any of the above details will result in the withdrawal of any job offer.

5 ADDITIONAL PERSONAL DETAILS

6 REFERENCES
Please give the name and address of two referees, one of whom must be your current or most recent previous employer. References from relatives or friends are not accepted.

This organisation seeks to work in a flexible and family friendly manner with its staff, however unsocial hours are part and parcel of a quality care service. Weekend working is a requirement for all staff, the frequency of which will be determined at interview.

Thank you for completing this application form.
I declare that to the best of my knowledge, all the information contained and documented here in is complete and truthful.

Application completed

yes No

Full employment history

yes No

References requested

yes No

Verbal reference check

yes No

Equal Opportunities Monitoring
This section of the application will be detached and used for monitoring purposes only. Our organisation recognises and actively promote the benefits of a diverse workforce and are committed to treating all employees with dignity and respect in line with the Equality Act 2010 legislation. We welcome applications from all sections of the community.

Gender

Male Female I do not wish to disclose this

Race Relations (Amendment) 2000
I would describe my ethnic origin as (please indicate with a X):

Asian or Asian British

White & Asian White & Black African White & Black Caribbean Any other mixed background

Black or Black British

Please select the option which best describes your sexuality

Please indicate your religion or belief

Health Questionnaire
(To be used for those applicants that have been deemed appointable).

To comply with the Equality Act 2010, please complete this questionnaire as fully as possible. Failure to do so could impede or delay your appointment. All information is confidential.

Have you ever had or suffered from?

Yes No

Epilepsy/Blackouts

Yes No

Nervous Mental Disorders

Yes No

Migraine/Headaches

Yes No

Sensory Impairment

Yes No

Skin Allergies

Yes No

Back pain/Previous Back Injury

Yes No

Heart Condition

Yes No

Asthmatic or respiratory ailments

Yes No

Recurring Incidence of Illness

Yes No

Are you registered disabled? (If yes, please detail below)

Yes No

Are you registered disabled? (If yes, please detail below)

Yes No

Please List below any vaccinations or immunisations

I declare that the information given is correct to the best of my knowledge. In my view, I am fit physically and mentally to undertake this post. I understand that omissions or false statements may disqualify me from employment or lead to dismissal. I give the employer the right to investigate all references.

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